- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $794.33 / $794.33 / $794.33
| Professional | | $794.33 | $794.33 | $794.33 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,398.83 / $2,884.03 / $3,467.37
| Professional | | $2,398.83 | $2,884.03 | $3,467.37 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $602.56 / $831.76 / $1,737.80
| Professional | | $602.56 | $831.76 | $1,737.80 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,995.26 / $6,456.54 / $8,317.64
| Facility | | $1,995.26 | $6,456.54 | $8,317.64 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $549.54 / $741.31 / $1,047.13
| Professional | | $549.54 | $741.31 | $1,047.13 |